U.S. DOD Form dod-dd-2807-1
REPORT OF MEDICAL HISTORY
(This information is for official and medically confidential use only and will not be released to unauthorized persons.)
Form Approved
OMB No. 0704-0413
Expires Oct 31, 2006
The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0413). Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB
control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM AS INDICATED ON PAGE 2.
PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397 (SSAN).
PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and
members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to
enter the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status.
WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or a $10,000 fine or both), to anyone making a false statement. If you are selected for enlistment, commission, or entrance into a
commissioning program based on a false statement, you can be tried by military courts-martial or meet an administrative board for discharge
and could receive a less than honorable discharge that would affect your future.
3. TODAY'S DATE (YYYYMMDD)
1. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)
2. SOCIAL SECURITY NUMBER
4.a. HOME ADDRESS (Street, Apartment No., City, State, and ZIP Code)
5. EXAMINING LOCATION AND ADDRESS (Include ZIP Code)
b. HOME TELEPHONE (Include Area Code)
7.a. POSITION (Title, Grade, Component)
X ALL APPLICABLE BOXES:
6.a. SERVICE
Coast
Guard
b. COMPONENT
c. PURPOSE OF EXAMINATION
Active Duty
Enlistment
Medical Board
Navy
Reserve
Commission
Retirement
Marine Corps
National Guard
Retention
U.S. Service Academy
Army
Air Force
Separation
8. CURRENT MEDICATIONS (Prescription and Over-the-counter)
Other (Specify)
b. USUAL OCCUPATION
ROTC Scholarship Program
9. ALLERGIES (Including insect bites/stings, foods, medicine or other substance)
Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 on Page 2.
HAVE YOU EVER HAD OR DO YOU NOW HAVE:
YES NO
12. (Continued)
f.
10.a. Tuberculosis
YES NO
Foot trouble (e.g., pain, corns, bunions, etc.)
g. Impaired use of arms, legs, hands, or feet
b. Lived with someone who had tuberculosis
h. Swollen or painful joint(s)
c. Coughed up blood
d. Asthma or any breathing problems related to exercise, weather,
i.
j.
Knee trouble (e.g., locking, giving out, pain or ligament injury, etc.)
f. Bronchitis
Any knee or foot surgery including arthroscopy or the use of a scope
to any bone or joint
k. Any need to use corrective devices such as prosthetic devices, knee
brace(s), back support(s), lifts or orthotics, etc.
g. Wheezing or problems with wheezing
l.
Bone, joint, or other deformity
pollens, etc.
e. Shortness of breath
h. Been prescribed or used an inhaler
m. Plate(s), screw(s), rod(s) or pin(s) in any bone
i.
A chronic cough or cough at night
n. Broken bone(s) (cracked or fractured)
j.
Sinusitis
13.a. Frequent indigestion or heartburn
k. Hay fever
b. Stomach, liver, intestinal trouble, or ulcer
l.
c. Gall bladder trouble or gallstones
Chronic or frequent colds
d. Jaundice or hepatitis (liver disease)
11.a. Severe tooth or gum trouble
e. Rupture/hernia
b. Thyroid trouble or goiter
c. Eye disorder or trouble
f.
d. Ear, nose, or throat trouble
g. Skin diseases (e.g. acne, eczema, psoriasis, etc.)
Rectal disease, hemorrhoids or blood from the rectum
e. Loss of vision in either eye
h. Frequent or painful urination
f.
Worn contact lenses or glasses
i.
High or low blood sugar
g. A hearing loss or wear a hearing aid
j.
Kidney stone or blood in urine
h. Surgery to correct vision (RK, PRK, LASIK, etc.)
k. Sugar or protein in urine
l. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital
12.a. Painful shoulder, elbow or wrist (e.g. pain, dislocation, etc.)
b. Arthritis, rheumatism, or bursitis
c. Recurrent back pain or any back problem
warts, herpes, etc.)
14.a. Adverse reaction to serum, food, insect stings or medicine
b. Recent unexplained gain or loss of weight
d. Numbness or tingling
c. Currently in good health (If no, explain in Item 29 on Page 2.)
e. Loss of finger or toe
d. Tumor, growth, cyst, or cancer
DD FORM 2807-1, OCT 2003
DoD exception to SF 93 approved by ICMR, August 3, 2000.
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 3 Pages
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LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)
SOCIAL SECURITY NUMBER
Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 below.
HAVE YOU EVER HAD OR DO YOU NOW HAVE:
YES NO
15.a. Dizziness or fainting spells
b. Frequent or severe headache
YES NO
19. Have you been refused employment or been unable to hold a job
or stay in school because of:
c. A head injury, memory loss or amnesia
a. Sensitivity to chemicals, dust, sunlight, etc.
d. Paralysis
b. Inability to perform certain motions
e. Seizures, convulsions, epilepsy or fits
c. Inability to stand, sit, kneel, lie down, etc.
f.
d. Other medical reasons (If yes, give reasons.)
Car, train, sea, or air sickness
g. A period of unconsciousness or concussion
h. Meningitis, encephalitis, or other neurological problems
16.a. Rheumatic fever
b. Prolonged bleeding (as after an injury or tooth extraction, etc.)
c. Pain or pressure in the chest
d. Palpitation, pounding heart or abnormal heartbeat
e. Heart trouble or murmur
f.
High or low blood pressure
17.a. Nervous trouble of any sort (anxiety or panic attacks)
b. Habitual stammering or stuttering
c. Loss of memory or amnesia, or neurological symptoms
d. Frequent trouble sleeping
e. Received counseling of any type
f. Depression or excessive worry
g. Been evaluated or treated for a mental condition
h.
i.
Attempted suicide
Used illegal drugs or abused prescription drugs
18. FEMALES ONLY. Have you ever had or do you now have:
a. Treatment for a gynecological (female) disorder
b. A change of menstrual pattern
20. Have you ever been treated in an Emergency Room?
(If yes, for what?)
21. Have you ever been a patient in any type of hospital? (If yes,
specify when, where, why, and name of doctor and complete
address of hospital.)
22. Have you ever had, or have you been advised to have any
operations or surgery? (If yes, describe and give age at which
occurred.)
23. Have you ever had any illness or injury other than those
already noted? (If yes, specify when, where, and give
details.)
24. Have you consulted or been treated by clinics, physicians,
healers, or other practitioners within the past 5 years for
other than minor illnesses? (If yes, give complete address
of doctor, hospital, clinic, and details.)
25. Have you ever been rejected for military service for any
reason? (If yes, give date and reason for rejection.)
26. Have you ever been discharged from military service for any
reason? (If yes, give date, reason, and type of discharge;
whether honorable, other than honorable, for unfitness or
unsuitability.)
d. First day of last menstrual period (YYYYMMDD)
27. Have you ever received, is there pending, or have you ever
applied for pension or compensation for any disability
or injury? (If yes, specify what kind, granted by whom,
and what amount, when, why.)
e. Date of last PAP smear (YYYYMMDD)
28. Have you ever been denied life insurance?
c. Any abnormal PAP smears
29. EXPLANATION OF "YES" ANSWER(S) (Describe answer(s), give date(s) of problem, name of doctor(s) and/or hospital(s), treatment given and current medical
status.)
NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY."
DD FORM 2807-1, OCT 2003
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Page 2 of 3 Pages
LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX)
SOCIAL SECURITY NUMBER
30. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician/practitioner shall comment on all positive answers in
questions 10 - 29. Physician/practitioner may develop by interview any additional medical history deemed important, and record any
significant findings here.)
a. COMMENTS
b. TYPED OR PRINTED NAME OF EXAMINER (Last, First, Middle Initial)
DD FORM 2807-1, OCT 2003
c. SIGNATURE
d. DATE SIGNED
(YYYYMMDD)
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